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ARD Online First, published on January 30, 2015 as 10.1136/annrheumdis-2014-206580
Criteria

Evidence-based provisional clinical classification

criteria for autoinflammatory periodic fevers
Silvia Federici,1 Maria Pia Sormani,2 Seza Ozen,3 Helen J Lachmann,4
Gayane Amaryan,5 Patricia Woo,6 Isabelle Koné-Paut,7 Natacha Dewarrat,8
Luca Cantarini,9 Antonella Insalaco,10 Yosef Uziel,11 Donato Rigante,12
Pierre Quartier,13 Erkan Demirkaya,14 Troels Herlin,15 Antonella Meini,16
Giovanna Fabio,17 Tilmann Kallinich,18 Silvana Martino,19 Aviel Yonatan Butbul,20
Alma Olivieri,21 Jasmin Kuemmerle-Deschner,22 Benedicte Neven,13 Anna Simon,23
Huri Ozdogan,24 Isabelle Touitou,25 Joost Frenkel,26 Michael Hofer,8
Alberto Martini,27 Nicolino Ruperto,1 Marco Gattorno,1 for the Paediatric
Rheumatology International Trials Organisation (PRINTO) and Eurofever Project

Handling editor Tore K Kvien
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please visit the journal online
(http://dx.doi.org/10.1136/
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end of article.
Correspondence to
Dr Marco Gattorno, UO
Pediatria 2, Istituto G Gaslini,
Largo G Gaslini 5, Genova
16147, Italy; marcogattorno@
ospedale-gaslini.ge.it
Received 5 September 2014
Revised 23 December 2014
Accepted 6 January 2015
To cite: Federici S,
Sormani MP, Ozen S, et al.
Ann Rheum Dis Published
Online First: [ please include
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doi:10.1136/annrheumdis-
2014-206580
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& EULAR) under licence.
ABSTRACT
The objective of this work was to develop and validate a
set of clinical criteria for the classification of patients
affected by periodic fevers. Patients with inherited
periodic fevers (familial Mediterranean fever (FMF);
mevalonate kinase deficiency (MKD); tumour necrosis
factor receptor-associated periodic fever syndrome
(TRAPS); cryopyrin-associated periodic syndromes (CAPS))
enrolled in the Eurofever Registry up until March 2013
were evaluated. Patients with periodic fever, aphthosis,
pharyngitis and adenitis (PFAPA) syndrome were used as
negative controls. For each genetic disease, patients
were considered to be ‘gold standard’ on the basis of
the presence of a confirmatory genetic analysis. Clinical
criteria were formulated on the basis of univariate and
multivariate analysis in an initial group of patients
(training set) and validated in an independent set of
patients (validation set). A total of 1215 consecutive
patients with periodic fevers were identified, and 518
gold standard patients (291 FMF, 74 MKD, 86 TRAPS,
67 CAPS) and 199 patients with PFAPA as disease
controls were evaluated. The univariate and multivariate
analyses identified a number of clinical variables that
correlated independently with each disease, and four
provisional classification scores were created. Cut-off
values of the classification scores were chosen using
receiver operating characteristic curve analysis as those
giving the highest sensitivity and specificity. The
classification scores were then tested in an independent
set of patients (validation set) with an area under the
curve of 0.98 for FMF, 0.95 for TRAPS, 0.96 for MKD,
and 0.99 for CAPS. In conclusion, evidence-based
provisional clinical criteria with high sensitivity and
specificity for the clinical classification of patients with
inherited periodic fevers have been developed.
INTRODUCTION
Autoinflammatory diseases include monogenic and
multifactorial inflammatory conditions charac-
terised by exaggerated activation of innate immun-
ity in response to exogenous or endogenous
stimuli, in the absence of high-titre autoantibodies.1
Most of these disorders are characterised by recur-
rent episodes of fever and are defined as periodic
Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580
fevers. Familial Mediterranean fever (FMF) is an
autosomal recessive (AR) disease secondary to
mutations of the MEFV (MEditerranean FeVer)
gene.2 3 It is characterised by short episodes of
fever (24–72 h) associated with serositis and arth-
ralgia/arthritis. Mevalonate kinase deficiency
(MKD; an AR disease) is caused by loss of function
of mevalonate kinase (MVK), an enzyme involved
in cholesterol biosynthesis.4 5 A partial enzymatic
defect causes episodes of fever lasting 4–6 days
associated with abdominal pain, diarrhoea, rash
and lymph node enlargement.6 The almost com-
plete absence of enzymatic activity is responsible
for a severe metabolic disease (mevalonic aciduria)
with chronic inflammation and severe neurological
impairment. Tumour necrosis factor (TNF)
receptor-associated periodic fever syndrome
(TRAPS) is an autosomal dominant (AD) disease
secondary to mutations of type 1 TNF receptor
(TNFSRF1A).7 Fever episodes last more than 6 days
and are associated with myalgia, rash and abdom-
inal pain.8 Cryopyrin-associated periodic syn-
dromes (CAPS) are a group of disorders associated
with heterozygous mutations of NLRP3, encoding
cryopyrin.9 The clinical spectrum of CAPS is
broad, ranging from a severe chronic infantile mul-
tisystemic inflammatory disease, defined as chronic
infantile cutaneous neurological articular (CINCA)
syndrome (or neonatal-onset multisystemic, chronic
inflammation disease (NOMID)), to a milder
phenotype with recurrent episodes of fever, urticar-
ial rash and arthralgia/arthritis.10
Inherited periodic fevers have been observed in
all studied ethnicities and populations, although
FMF has a particularly high prevalence in Turkish,
Arab, Armenian and non-Ashkenazi Jewish popula-
tions.11 Disease onset is usually in the first years of
life. However, a variable proportion of patients
(especially those with FMF and TRAPS) might
present first symptoms in their second or third
decade of life.11 12 Typical ‘inflammatory’ fever epi-
sodes can also be observed in a relatively common
non-monogenic autoinflammatory disease, named
PFAPA ( periodic fever, aphthosis, pharyngitis and
adenitis) syndrome, characterised by strikingly
1
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Criteria
regular episodes of fever variably associated with at least one of
the three manifestations in the acronym in the absence of signs
of infection.13
The diagnosis of inherited periodic fevers relies on careful
interpretation of the clinical phenotype and results from
molecular genetic analysis. Molecular analysis is able to provide
a definitive diagnosis in most patients, but the results can be
inconclusive or even misleading in other cases.14 As a result,
there have been previous attempts to provide clinical guidelines
and diagnostic flowcharts to identify appropriate cases for
testing.6 15–17
Formal diagnostic criteria have been developed for some
inherited periodic fevers (FMF and mild CAPS) based on the
main clinical manifestations associated with the specific disease
within the context of limited populations, and there is some
question of their suitability for use in other populations.18–21
The aim of the present study was to take advantage of a large
international registry of autoinflammatory diseases (Eurofever)
to develop and validate evidence-based clinical classification cri-
teria for the four main autoinflammatory periodic fevers in chil-
dren and adults.
PATIENTS AND METHODS
Data were extracted from the Eurofever Registry.11 The main
characteristics of the registry, the diseases involved and the method
of selecting the variables included in the forms have already been
described11 22 (see online supplementary appendix I). Ethics com-
mittee approval for entering patients in the registry and informed
consent or assent were obtained in the participating centres,
depending on each country’s regulations. For the purpose of this
study, the following diseases characterised by periodic/recurrent
fever episodes were analysed: FMF, MKD, TRAPS and CAPS.
Patients with PFAPA were used as disease controls.
Selection of the ‘gold standard’ group and statistical analysis
The Eurofever Registry Steering Committee has appointed a
group of experienced clinicians (SO, HO for FMF; JF, AS for
MKD; HL, MG, PW for TRAPS; BN, JK-D for CAPS; MH,
MG for PFAPA) to evaluate web-collected cases available in the
registry. The disease experts have the mandate to control the
consistency and quality of the data. In the case of inconsistency
or other uncertainty, specific queries are resubmitted to the par-
ticipating centres for resolution.
The reference ‘gold standard’ group includes patients with
FMF, TRAPS, CAPS or MKD with a confirmatory molecular
analysis14 defined as follows:
▸ FMF: two MEFV mutations, of which at least one is in exon
1023;
▸ MKD: two MVK mutations with the exclusion of variants
with an uncertain pathological role (such as S52N P165L,
H20Q) (http://fmf.igh.cnrs.fr/infevers/)23;
▸ TRAPS: heterozygous TNFRSF1A mutations with the exclu-
sion of low-penetrance (such as R92Q or P46L) or uncertain
mutations (http://fmf.igh.cnrs.fr/infevers/)23;
▸ CAPS: heterozygous NLRP3 mutations with the exclusion of
low-penetrance variants (V198M), functional polymorphisms
(Q703K) or variants with uncertain pathological role (http://
fmf.igh.cnrs.fr/infevers/).23
Other patients with a non-confirmatory genetic test (eg, one
mutation in AR disease, low-penetrance mutations, polymorph-
isms) were considered to be ‘genetically uncertain patients’ and
were excluded from the statistical analysis. With the exclusion of
patients with severe CAPS presenting a neonatal-onset chronic
disease course, the majority of patients with a confirmatory
2 Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580
genetic test showed a recurrent disease course (see below). For
this reason, patients with a chronic disease course were not con-
sidered for the elaboration of the criteria. Patients with PFAPA
were classified according to current diagnostic criteria.24 Before
the analysis, the centres were retrospectively contacted and asked
whether, during the follow-up after enrolment, the diagnosis of
PFAPA could be confirmed or if a different diagnosis was pointed
to. Patients whose disease was not confirmed by the centres or
who were lost to follow-up were excluded. So that the classifica-
tion criteria could be developed and subsequently validated on
an independent set of patients, the gold standard group was ran-
domly split into two subgroups in a ratio of 3:2. The first (‘train-
ing set’) was used to identify clinical variables that were able to
correctly classify each disease through a classification score. The
second group (‘validation set’) was used to verify the perform-
ance of the classification score created on the training set.
Statistical analysis was performed and clinical criteria were
formulated on the basis of a univariate and multivariate analysis
of the training set and validated on the validation set, as previ-
ously described16 (see online supplementary appendix II).
RESULTS
Selection and characterisation of the gold standard group
From November 2009 to March 2013, 2556 patients (1258
male, 1298 female) were collected in the Eurofever Registry by
91 centres in 56 countries (see online supplementary figure S1).
Of these 2556 patients, 658 were excluded because they had
not yet been checked by experts; 590 with confirmed autoin-
flammatory disease not associated with periodic fever (defi-
ciency of IL-1 receptor agonist (DIRA), pyogenic arthritis,
pyoderma gangrenosum and acne (PAPA), chronic recurrent
multifocal osteomyelitis (CRMO), Blau’s syndrome) and 93
with a chronic disease course (58 CAPS, 13 FMF, 14 TRAPS, 8
MKD; see online supplementary figure S2) were also excluded.
The remaining 1215 patients with periodic fevers (498 FMF,
112 MKD, 164 TRAPS, 105 CAPS, 336 PFAPA) were evaluated.
A total of 518 patients with inherited periodic fevers were
selected as the gold standard group (291 FMF, 74 MKD, 86
TRAPS, 67 CAPS). The other 361 patients with inherited peri-
odic fevers were classified as genetically uncertain patients. In
addition, 199 patients with PFAPA were included in the study as
disease controls, after final confirmation by the centres at the
last follow-up (see online supplementary figure S2).
The main demographic and clinical features of the gold stand-
ard patients and patients with PFAPA are reported in table 1.
The results of the molecular analysis are reported in online sup-
plementary table S1. At the time of enrolment, 483 (67.3%)
patients were paediatric (<14 years) and 234 (33.7%) were
adults. Disease onset was reported during childhood in 671
patients (93.7%) (see online supplementary figure S3).
Development of a clinical classification score and
performance in the validation set
The 518 gold standard and 199 PFAPA patients were randomly
split into a training (n=412) and a validation (n=305) set; the
main demographic characteristics of the two groups are sum-
marised in online supplementary table S2. Univariate analysis
performed on the training set identified clinical variables asso-
ciated with each disease (see online supplementary table S3).
The results of multivariate analysis performed on the training
set are reported in table 2. For each disease, the symptoms that
independently discriminate it from the other disorders are
reported, together with the weights estimated by the logistic
model. The score for each disease is calculated by summing all
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Table 1 Principal demographic features and clinical manifestations in gold standard patients
Characteristic FMF (291 patients) MKD (74 patients) TRAPS (86 patients) CAPS (67 patients) PFAPA (199 patients)

Age (years), median (25°–75°) 11.9 (8.3–14.9) 11.31 (6.6–22.3) 34.2 (14.9–44.9) 15.1 (9.0–42.7) 5 (3.7–7.5)
Gender, male/female 161/130 36/38 43/43 34/33 112/87
Positive family history, % 42.3 33.8 66.3 60.9 7.6
Age at onset (years), median (25°–75°) 2.7 (1.1–5.3) 0.4 (0.1–1.4) 2.8 (0.6–8.8) 0.7 (0.1–2.9) 1.6 (1–3.5)
Duration of disease (years), median (25°–75°) 7.2 (4.2–11.1) 9.8 (5.8–20.8) 21.1 (10.7–37.1) 13.1 (7.0–40.1) 2.8 (1.7–4.3)
Abdominal pain, % 93 86 74 11 36
Aphthous stomatitis, % 5 62 6 18 68
Arthralgia, % 79 69 64 92 26
Aseptic peritonitis, % 20 6 8 0 0
Bone alteration, % 1 1 1 27 0
Chest pain, % 63 11 25 4 1
Conjunctivitis, % 5 11 36 71 4
Diarrhoea, % 27 86 16 3 10
Enlarged cervical lymph nodes, % 18 89 40 15 70
Erythematous pharyngitis, % 23 41 14 6 63
Exudative pharyngitis, % 8 31 2 2 74
Fatigue, % 40 68 83 65 22
Generalised enlargement of lymph nodes, % 3 36 10 13 5
Headache (any time), % 25 52 14 69 16
Maculopapular rash, % 6 37 31 19 6
Migratory rash, % 0 1 28 8 0
Myalgia, % 63 53 75 51 14
Neurosensorial hearing loss, % 0 2 0 44 0
Oligoarthritis, % 30 14 10 25 1
Painful lymph nodes, % 12 60 22 3 18
Papilloedema, % 0 0 0 31 0
Pericarditis, % 24 3 12 3 0
Periorbital oedema, % 1 0 25 3 1
Pleurisy, % 40 3 12 0 0
Urticarial rash, % 5 17 29 100 3
Vomiting, % 50 68 13 7,5 14
CAPS, cryopyrin-associated periodic syndromes; FMF, familial Mediterranean fever; MKD, mevalonate kinase deficiency; PFAPA, periodic fever, aphthosis, pharyngitis and adenitis;
TRAPS, receptor-associated periodic fever syndrome.

the weights associated with the presence or absence of symp-
toms in each patient (table 3).
The discriminative ability of the linear scores calculated for
each disease was assessed on the training set by receiver operat-
ing characteristic (ROC) curve analysis (figure 1); for each
disease, an optimal cut-off, based on the point on the ROC
curve giving maximum accuracy, was chosen to classify patients
as diseased/not diseased. The scores and cut-offs calculated on
the training set according to the above procedure were then
applied to the validation set, calculating the sensitivity and
specificity of the score on this independent set of patients. In
figure 1 the performance of the classification criteria on the
training set is compared with the performance obtained with
the validation set. All criteria displayed high sensitivity and spe-
cificity, with an area under the curve above 0.90 in all subgroups
(figure 1).
The performances of the four scores providing the best accur-
acy in the total group of gold standard patients (validation and
training sets) according to the different diseases are shown in
online supplementary figure S4. In 144 patients (19.7%), a
double classification was obtained. In this case, the threshold of
increase above the cut-off value related to the correct diagnosis
was generally higher than those obtained for the incorrect diag-
nosis (see online supplementary table S4). Only 10 patients
(1.3%) did not receive any classification.
Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580
Different cut-off values providing a higher sensitivity and the
cut-off values providing a higher specificity for each disease are
also shown in online supplementary figure S4. Even with a
lower specificity (see legend to online supplementary figure S4),
the use of a ‘high-sensitivity score’ would allow the identifica-
tion of more than 95% of patients, minimising the risk of
excluding possibly affected patients from the molecular analysis
during the diagnostic work-out.
Performance of the classification score for patients with a
non-confirmatory genetic test (genetically uncertain
patients) and patients with a chronic disease course
The clinical and molecular features of 361 patients without a
confirmatory genetic test are reported in online supplementary
tables S5 and S6, and performances of the classification criteria
in this subgroup are reported in table 4. The overall specificity
of the most accurate criteria was generally high. The highest
numbers of FMF-like patients who were positive according to
the FMF score were those carrying two MEFV mutations not in
exon 10, the heterozygous patients with mutations in exon 10,
and patients not genetically screened (75%). A similar percent-
age of positivity was observed in CAPS-like patients, including
those carrying the V198M low-penetrance variant and the
Q703K polymorphism. Conversely, only 52% of patients
carrying the R92Q variant of TNFRFS1A, a low-penetrance
3
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Criteria

mutation, usually associated with a milder phenotype,25 were

positive according to the score.

0.1 (0.01 to 0.6)

5.1 (1.4 to 17.8)

6.3 (1.7 to 23.6)

3.1 (1.0 to 12.2)

102 (13 to 812)
We also verified the performance of classification criteria in

3.9 (1.015.53)
OR (95% CI)

18 (5 to 67)
the group of patients with a chronic disease course (see online

p<0.0001

p<0.0001

p=0.001
supplementary table S7). The vast majority of CAPS patients

p=0.01

p=0.05

p=0.05

p=0.01
with a chronic disease course (mainly CINCA/NOMID) were
positive according to the Eurofever classification criteria. The
same was observed for patients with other diseases, especially

lymph nodes or splenomegaly

Diarrhoea (sometimes/often)

Generalised enlargement of
those with a confirmatory genetic test (see online supplementary
table S8).

Age at onset <2 years

Painful lymph nodes

Aphthous stomatitis
Diarrhoea (always)

DISCUSSION
We propose a new set of provisional classification criteria for
Symptoms

Chest pain
patients with inherited autoinflammatory diseases presenting
MKD

with periodic fever. Multivariate analysis on a large group of

patients with different periodic fevers has allowed identification
of a set of variables that gave a very high performance in an
0.04 (0 to 0.15) p<0.0001

independent group of patients. These criteria are aimed to help

experts in the field correctly clinically classify patients with sus-
290 (30 to 2757)

9.1 (2.2 to 36.6)

274 (8 to 8944)

0.004 (0 to 1.0)

pected autoinflammatory disease and should be applied only

OR (95% CI)

after careful exclusion of other causes of periodic fevers, such as

p<0.0001

p=0.002

p=0.002

CAPS, cryopyrin-associated periodic syndromes; FMF, familial Mediterranean fever; MKD, mevalonate kinase deficiency; TRAPS, receptor-associated periodic fever syndrome. infections, immunodeficiency, neoplasms, and other rheumatic
p=0.05

conditions with uncertain genotype.

A factual limitation of the study was the decision to create the
criteria on the basis of clinical findings observed in gold stand-
Neurosensory hearing loss

ard patients with a confirmatory genetic test. This approach

Exudative pharyngitis

potentially overemphasises ‘classical’ presentations of the dis-

Abdominal pain

eases, limiting recognition of patients with atypical phenotypes.

Urticarial rash

Conjunctivitis

Certainly, clinical criteria need to be considered in the light of

Symptoms

information from molecular analysis, and vice versa, they need

CAPS

to enable recognition of patients with clear-cut pathogenic

mutations even with an unusual clinical presentation. For this
reason, we propose to attribute the term ‘provisional’ to the
0.12 (0.03 to 0.54)

0.07 (0.02 to 0.3)

5.3 (1.7 to 16.9)

proposed criteria.
2.5 (1.0 to 7.1)
23 (2.5 to 206)

11 (1.0 to 209)
49 (15 to 165)
OR (95% CI)

All diagnostic or classification criteria and guidelines for

p<0.0001

p=0.0001

p=0.004

p=0.006

p<0.001

genetic analysis available in the literature to date have been

p=0.05

p=0.05

developed on the basis of expert opinion or on evaluation of

Table 2 Results of the multivariate analysis in gold standard patients (training set)

clinical manifestations in patients affected by a single disease,

usually in the context of a limited population or ethnic back-
Duration of episodes >6 days

ground.6 8 15–20 24 The wide overlap of the clinical features

associated with episodes of fever in these conditions is the
Aphthous stomatitis

major cause of the low performance of these diagnostic criteria

Periorbital oedema

Relatives affected

when applied to patients affected by different autoinflammatory

Migratory rash

diseases.16 26 In the present study, we followed an alternative

Symptoms

Vomiting
Myalgia

approach to the previous classical consensus of experts, which is

TRAPS

commonly used for diseases for which a specific diagnostic

marker is lacking.27 The availability of the large international
Eurofever Registry has, for the first time, enabled comparison of
patients with different diseases, but with a common data collec-
2975 (87 to 22 543)

0.001 (0.001 to 0.1)

0.05 (0.005 to 0.4)

0.04 (0.004 to 0.5)

0.002 (0.01 to 0.1)

tion, and of heterogeneous geographic and ethnic distribution.

166 (7 to 017)

This approach allowed identification of ‘positive’ and ‘negative’

68 (7 to 660)

33 (3 to 329)

14 (1 to 201)
OR (95% CI)

criteria correlated with each disease, resulting in the high accur-

p<0.0001

p<0.0001

p<0.0001

p=0.0002

p<0.0001
p=0.004

p=0.003
p=0.05

p=0.01

acy observed for each set of criteria.

This new set of criteria might represent a useful practical tool
to be used in daily clinical practice for patients with suspected
Eastern Mediterranean ethnicity

autoinflammatory disease—either for the selection of genes suit-

Enlarged cervical lymph nodes
North Mediterranean ethnicity

Duration of episodes <2 days

Duration of episodes >6 days

able for molecular analysis and for their final classification after
genetic tests, or when an unpublished genetic mutation is found
Aphthous stomatitis

in a given patient, or when the genetic testing is not clearly con-

firmatory. In the first case, the use of the ‘high-sensitivity score’
Abdominal pain

Urticarial rash

would minimise the risk of excluding possible positive patients

Symptoms

Chest pain

from genetic analysis.

FMF

Depending on the pattern of inheritance, the identification of

one or two mutations with known pathogenic impact and high
4 Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580
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Table 3 The Eurofever clinical diagnostic/classification criteria*

FMF MKD CAPS TRAPS

Presence Score Presence Score Presence Score Presence Score

Duration of episodes < 2 days 9 Age at onset <2 years 10 Urticarial rash 25 Periorbital oedema 21
Chest pain 13 Aphthous stomatitis 11 Neurosensorial hearing loss 25 Duration of episodes >6 days 19
Abdominal pain 9 Generalised enlargement of 8 Conjunctivitis 10 Migratory rash† 18
lymph nodes or splenomegaly
Eastern Mediterranean‡ ethnicity 22 Painful lymph nodes 13 Myalgia 6
North Mediterranean‡ ethnicity 7 Diarrhoea (sometimes/often) 20 Relatives affected 7
Diarrhoea (always) 37

Absence Absence Absence Absence

Aphthous stomatitis 9 Chest pain 11 Exudative pharyngitis 25 Vomiting 14

Urticarial rash 15 Abdominal pain 15 Aphthous stomatitis 15
Enlarged cervical lymph nodes 10
Duration of episodes >6 days 13

Cut-off ≥60 Cut-off ≥42 Cut-off ≥52 Cut-off ≥43

*The clinical features should be related to the typical fever episodes (ie, exclusion of intercurrent infection or other comorbidities).†Centrifugal migratory, erythematous patches most
typically overlying a local area of myalgia, usually on the limbs or trunk.
‡Eastern Mediterranean: Turkish, Armenian, non-Ashkenazi Jewish, Arab. North Mediterranean: Italian, Spanish, Greek.
CAPS, cryopyrin-associated periodic syndromes; FMF, familial Mediterranean fever; MKD, mevalonate kinase deficiency; TRAPS, receptor-associated periodic fever syndrome.

penetrance represents an essential final step in the diagnosis of
monogenic autoinflammatory diseases.14 However, in a consid-
erable proportion, molecular analysis is unable to provide diag-
nostic confirmation—for example, in the case of a single
mutation in AR disorders or the identification of variants of
unknown significance such as low-penetrance mutations, func-
tional polymorphisms, and novel variants of unknown func-
tional impact.14 28 To further complicate this issue, the
extensive use of molecular analysis over the last few years has
revealed a growing number of patients carrying mutations in

Figure 1 Receiver operating

characteristic curves obtained for
training (TS) and validation (VS) sets of
gold standard patients, and the
sensitivity (Sens) and specificity (Spec)
of each classification criterion. AUC,
area under the curve; CAPS,
cryopyrin-associated periodic
syndromes; FMF, familial
Mediterranean fever; MKD, mevalonate
kinase deficiency; TRAPS,
receptor-associated periodic fever
syndrome.

Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580 5

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Table 4 Performance of Eurofever classification criteria in genetically uncertain patients

FMF (207 patients) TRAPS (78 patients) CAPS (38 patients) MKD (38 patients)

Overall sensitivity 68% Overall sensitivity 59% Overall sensitivity 70% Overall sensitivity 53%
Overall specificity 87% Overall specificity 84% Overall specificity 95% Overall specificity 89%
Percentage of patients positive according to the criteria for different genotypes
2 mutations (not in exon 10) 75% R92Q mutation (53 patients) 52% V198M mutation 75% Heterozygous (24 patients) 62%
(16 patients) (13 patients)
1 mutation in exon 10 75% Other low-penetrance mutations 47% Q703K mutation (7 patients) 72% Genetically negative 0%
(92 patients) (18 patients) (7 patients)
1 mutation not in exon 55% Genetically negative (6 patients) 83.3% Genetically negative 50% Genetic test not done 60%
10 (34 patients) (2 patients) (7 patients)
No MEFV mutations (45 patients) 51% Genetic test not done (1 patient) 100% Genetic test not done 69%
(16 patients)
Genetic test not done (20 patients) 75%
CAPS, cryopyrin-associated periodic syndromes; FMF, familial Mediterranean fever; MKD, mevalonate kinase deficiency; MEFV, Mediterranean fever; TRAPS, receptor-associated periodic
fever syndrome.

more than one gene.29 Non-confirmatory genetic results
provide a challenge for both physicians and geneticists and may
lead to overestimation of the pathogenic relevance of genetic
variants in patients presenting with an unclear inflammatory
phenotype.14 This problem will become more pressing with the
application of next-generation sequencing, a technique that
holds promise as a potent diagnostic tool for periodic fevers
and other genetic disorders. This will almost certainly result in
identification of a huge number of variants of unknown signifi-
cance in the genes associated with periodic fevers. As a result,
studies such as this, which both correlate and validate data from
molecular analysis and the clinical phenotype, will become more
critical both for correct classification of patients and assessing
the impact or otherwise of genetic variants.
Application of the Eurofever classification criteria in patients
without genetic confirmation and in patients with a chronic
disease course revealed some interesting features. Despite some
variability related to the different genotypes, a high proportion of
patients with a non-confirmatory genetic test in the present study
turned out to be positive with a high accuracy score. These results
should nonetheless be interpreted with caution, as it is probable
that the considerable number of these patients fulfilling the clinical
classification criteria in this study is due to a bias in patient selec-
tion by the registry, which is strongly predisposed towards patients
for whom the enrolling centres have a serious suspicion of a given
disease.12 It is likely that application of the new classification cri-
teria in daily practice, in which a less rigorously selected popula-
tion is present ( patients with a non-confirmatory genetic test or
positive for more than one gene, undifferentiated patients with a
negative genetic test), might influence the actual accuracy of the
present criteria. This possibility is being verified in a prospective
validation of the criteria in a random population of patients with
suspected autoinflammatory diseases.
Even though the criteria were developed and validated in
patients with periodic fever, the performance of the diagnostic/
classification criteria was also particularly high in patients pre-
senting with a chronic disease course. Even though 97% of
CAPS patients with a chronic disease course were correctly iden-
tified by the present criteria, it is conceivable that CAPS merits
specific diagnostic/classification criteria that could cover all pos-
sible NLRP3-associated phenotypes, including those clinical fea-
tures (severe neurological involvement, bone alterations, etc)
related to the most severe clinical phenotype (CINCA/NOMID),
usually presenting with a chronic inflammatory disease course
from birth. For similar reasons, we believe that the present score
is not suitable for the diagnosis and classification of the most
severe form of MKD deficiency, mevalonic aciduria.
In conclusion, we present a validated evidence-based tool
either for indication for molecular analysis or for clinical classifi-
cation of patients with suspected autoinflammatory periodic
fevers after careful exclusion of other causes. Future work build-
ing on this will include prospective validation of the criteria in
everyday clinical practice and a consensus process among paedi-
atric and adult clinicians and genetic experts in the field to gen-
erate guidelines for the correct combination of these clinical
classification criteria and other possible clinical variables, such
as response to treatment or specific laboratory examinations (eg,
urinary mevalonic acid for MKD), with information from
molecular analysis to provide definitive classification of patients
with autoinflammatory periodic fevers.
Author affiliations
1
UO Pediatria II–Reumatologia, Istituto Giannina Gaslini, Genova, Italy
2
Unità di Biostatistica, DISSAL, University of Genoa, Genova, Italy
3
Department of Pediatric Rheumatology, Hacettepe University, Ankara, Turkey
4
National Amyloidosis Centre, University College London, London, UK
5
National Pediatric Familial Mediterranean Fever Centre, Institute of Child and
Adolescent Health, Yerevan, Armenia
6
Center of Paediatric and Adolescent Rheumatology, UCL, London, UK
7
Centre de référence national des maladies auto-inflammatoires, CEREMAI,
rhumatologie pédiatrique, CHU Le Kremlin Bicêtre (APHP, University of Paris SUD),
Paris, France
8
Pediatric Rheumatology Unit of Western Switzerland, CHUV, University of Lausanne,
Lausanne, and HUG, Geneva, Switzerland
9
Rheumatology Unit, Policlinico le Scotte, University of Siena, Siena, Italy
10
Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù
Children’s Hospital, IRCCS, Rome, Italy
11
Department of Pediatrics, Meir Medical Centre, Kfar Saba, Israel
12
Department of Pediatrics, Università Cattolica Sacro Cuore, Roma, Italy
13
Université Paris-Descartes, Hôpital Necker-Enfants Malades, Centre de référence
national pour les Arthrites Juveniles, Unité d’Immunologie, Hématologie et
Rhumatologie Pédiatrique, Université Descartes, Sorbonne Paris Cité, Institut
IMAGINE, Paris, France
14
Gulhane Military Medical Faculty, FMF Arthritis Vasculitis and Orphan Disease
Research Center (FAVOR), Ankara, Turkey
15
Department of Pediatrics, Aarhus University Hospital, Pediatric Rheumatology
Clinic, Aarhus, Denmark
16
Dipartimento di Pediatria, Unità di Immunologia e Reumatologia Pediatrica, Clinica
Pediatrica dell’Università di Brescia, Brescia, Italy
17
Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Clinica Pediatrica II
De Marchi, Milano, Italia
18
Kinderklinik, Rheumatologie, Charite University Hospital Berlin, Berlin, Germany
19
Dipartimento di Scienze Pediatriche e dell’Adolescenza, Clinica Pediatrica
Universita’ di Torino, Torino, Italy
20
Department of Pediatrics, Rambam Medical Center, Haifa, Israel
21
Dipartimento di Pediatria F Fede, Seconda Universita’ degli Studi di Napoli, Napoli,
Italia

6 Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580

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22
Universitatsklinik fur Kinderheilkunde und Jugendmedizin, Tübingen, Germany
23
Department of General Internal Medicine, Radboud University Medical Centre,
Nijmegen, The Netherlands
24
Ic Hastaliklari ABD, Romatoloji BD, Cerrahpasa Tip Fakultesi, Istanbul, Turkey
25
Unit of autoinflammatory diseases, Montpellier, UM1, INSERM U844, Montpellier,
France
26
Department of Paediatrics, University Medical Center Utrecht, Utrecht,
The Netherlands
27
Istituto Giannina Gaslini, Pediatria II and Università degli Studi di Genova, Genova,
Italy
Acknowledgements We thank the research assistants, Eugenia Mosci and Irene
Gregorini, for their valuable and excellent work. We also thank all members of
Eurofever/PRINTO who participated as investigators in the study on patients with
periodic fevers and whose enthusiastic efforts made this work possible: Argentina:
Graciela Espada, Ricardo Russo, Carmen De Cunto; Australia: Christina Boros; Chile:
Arturo Borzutzky; Croatia: Marija Jelusic-Drazic; Czech Republic: Pavla Dolezalova;
Denmark: Susan Nielsen; France: Veronique Hentgen; Germany: Tobias Schwarz,
Rainer Berendes, Annette Jansson, Gerd Horneff; Greece: Efimia
Papadopoulou-Alataki, Elena Tsitsami, Florence Kanakoudi Tsakalidou; Italy: Romina
Gallizzi, Laura Obici, Patrizia Barone, Rolando Cimaz, Mariolina Alessio, Japan:
Ryuta Nishikomori; Latvia: Valda Stanevicha; Netherlands: Esther Hoppenreijs;
Poland: Beata Wolska-Kusnierz; Romania: Nicolae Iagaru; Russia Federation: Irina
Nikishina; Saudi Arabia: Sulaiman M. Al-Mayouf, Sewairi; Serbia: Gordana Susic.
Slovenia: Natasa Toplak; Spain: Consuelo Modesto, Maria Jesus Rua Elorduy, Jordi
Anton, Rosa Bou.
Contributors SF, MPS, NR and MG: coordination of the study, analysis of the
data, manuscript preparation. SO, HJL, GA, PW, IK-P, ND, LC, AI, YU, DR, PQ, ED,
TH, AM, GF, TK, SM, AYB, AO, JK-D, BN, AS, HO, IT, JF, MH, AM: data collection
and analysis, revision of the manuscript.
Funding The Eurofever Registry was sponsored by the Autoinflammatory Diseases’
Working Group of the Paediatric Rheumatology European Society (PRES) and
supported by the Executive Agency For Health and Consumers (EAHC, Project No
2007332) and by Coordination Theme 1 (Health) of the European Community’s FP7
(Eurotraps, grant agreement number HEALTH-F2-2008-200923). Novartis and SOBI
granted unrestricted educational grants.
Competing interests None.
Ethics approval G Gaslini ethics board.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Additional material is published online only.
REFERENCES
1 Masters SL, Simon A, Aksentijevich I, et al. Horror autoinflammaticus: the molecular
pathophysiology of autoinflammatory disease (*). Annu Rev Immunol
2009;27:621–68.
2 The French FMF Consortium. A candidate gene for familial Mediterranean fever.
Nature Genetics 1997;17:25–31.
3 The International FMF Consortium. Ancient missense mutations in a new member
of the RoRet gene family are likely to cause familial Mediterranean fever. Cell
1997;90:797–807.
4 Drenth JP, Cuisset L, Grateau G, et al. Mutations in the gene encoding mevalonate
kinase cause hyper-IgD and periodic fever syndrome. International Hyper-IgD Study
Group. Nat Genet 1999;22:178–81.
5 Houten SM, Kuis W, Duran M, et al. Mutations in MVK, encoding mevalonate
kinase, cause hyperimmunoglobulinaemia D and periodic fever syndrome. Nature
Genetics 1999;22:175–7.
6 van der Hilst JC, Bodar EJ, Barron KS, et al. Long-term follow-up, clinical features,
and quality of life in a series of 103 patients with hyperimmunoglobulinemia D
syndrome. Medicine (Baltimore) 2008;87:301–10.
Federici S, et al. Ann Rheum Dis 2015;0:1–7. doi:10.1136/annrheumdis-2014-206580
Criteria
7 McDermott MF, Aksentijevich I, Galon J, et al. Germline mutations in the
extracellular domains of the 55 kDa TNF receptor, TNFR1, define a family of
dominantly inherited autoinflammatory syndromes. Cell 1999;97:133–44.
8 Hull KM, Drewe E, Aksentijevich I, et al. The TNF receptor-associated periodic
syndrome (TRAPS): emerging concepts of an autoinflammatory disorder. Medicine
(Baltimore) 2002;81:349–68.
9 Hoffman HM, Mueller JL, Broide DH, et al. Mutation of a new gene encoding a
putative pyrin-like protein causes familial cold autoinflammatory syndrome and
Muckle-Wells syndrome. Nat Genet 2001;29:301–5.
10 Aksentijevich I, Putnam D, Remmers EF, et al. The clinical continuum of
cryopyrinopathies: novel CIAS1 mutations in North American patients and a new
cryopyrin model. Arthritis Rheum 2007;56:1273–85.
11 Toplak N, Frenkel J, Ozen S, et al. An international registry on autoinflammatory
diseases: the Eurofever experience. Ann Rheum Dis 2012;71:1177–82.
12 Lachmann HJ, Papa R, Gerhold K, et al. The phenotype of TNF receptor-associated
autoinflammatory syndrome (TRAPS) at presentation: a series of 158 cases from
the Eurofever/EUROTRAPS international registry. Ann Rheum Dis 2014;73:
2160–7.
13 Marshall GS, Edwards KM, Butler J, et al. Syndrome of periodic fever, pharyngitis,
and aphthous stomatitis. J Pediatr 1987;110:43–6.
14 Shinar Y, Obici L, Aksentijevich I, et al. Guidelines for the genetic diagnosis of
hereditary recurrent fevers. Ann Rheum Dis 2012;71:1599–605.
15 Federici L, Rittore-Domingo C, Kone-Paut I, et al. A decision tree for genetic
diagnosis of hereditary periodic fever in unselected patients. Ann Rheum Dis
2006;65:1427–32.
16 Gattorno M, Sormani MP, D’Osualdo A, et al. A diagnostic score for molecular
analysis of hereditary autoinflammatory syndromes with periodic fever in children.
Arthritis Rheum 2008;58:1823–32.
17 Simon A, van der Meer JWM, Vesely R, et al. Approach to genetic analysis in the
diagnosis of hereditary autoinflammatory syndromes. Rheumatology
2006;45:269–73.
18 Livneh A, Langevitz P, Zemer D, et al. Criteria for the diagnosis of familial
Mediterranean fever. Arthritis Rheum 1997;40:1879–85.
19 Yalcinkaya F, Ozen S, Ozcakar ZB, et al. A new set of criteria for the diagnosis
of familial Mediterranean fever in childhood. Rheumatology (Oxford)
2009;48:395–8.
20 Sohar E, Gafni J, Pras M, et al. Familial Mediterranean fever. A survey of 470 cases
and review of the literature. Am J Med 1967;43:227–53.
21 Hoffman HM, Wanderer AA, Broide DH. Familial cold autoinflammatory syndrome:
phenotype and genotype of an autosomal dominant periodic fever. J Allergy Clin
Immunol 2001;108:615–20.
22 Ter HN, Lachmann H, Ozen S, et al. Treatment of autoinflammatory diseases:
results from the Eurofever Registry and a literature review. Ann Rheum Dis
2013;72:678–85.
23 Milhavet F, Cuisset L, Hoffman HM, et al. The infevers autoinflammatory
mutation online registry: update with new genes and functions. Hum Mutat
2008;29:803–8.
24 Thomas KT, Feder HM, Lawton AR, et al. Periodic fever syndrome in children.
J Pediatr 1999;135:15–21.
25 Ravet N, Rouaghe S, Dode C, et al. Clinical significance of P46L and R92Q
substitutions in the tumour necrosis factor superfamily 1A gene. Ann Rheum Dis
2006;65:1158–62.
26 Gattorno M, Caorsi R, Meini A, et al. Differentiating PFAPA syndrome from
monogenic periodic fevers. Pediatrics 2009;124:e721–8.
27 Ozen S, Pistorio A, Iusan SM, et al. EULAR/PRINTO/PRES criteria for
Henoch-Schonlein purpura, childhood polyarteritis nodosa, childhood Wegener
granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final
classification criteria. Ann Rheum Dis 2010;69:798–806.
28 Aksentijevich I, Kastner DL. Genetics of monogenic autoinflammatory diseases: past
successes, future challenges. Nat Rev Rheumatol 2011;7:469–78.
29 Touitou I, Hentgen V, Kone-Paut I. Web resources for rare auto-inflammatory
diseases: towards a common patient registry. Rheumatology (Oxford)
2009;48:665–9.
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Evidence-based provisional clinical

classification criteria for autoinflammatory
periodic fevers
Silvia Federici, Maria Pia Sormani, Seza Ozen, Helen J Lachmann,
Gayane Amaryan, Patricia Woo, Isabelle Koné-Paut, Natacha Dewarrat,
Luca Cantarini, Antonella Insalaco, Yosef Uziel, Donato Rigante, Pierre
Quartier, Erkan Demirkaya, Troels Herlin, Antonella Meini, Giovanna
Fabio, Tilmann Kallinich, Silvana Martino, Aviel Yonatan Butbul, Alma
Olivieri, Jasmin Kuemmerle-Deschner, Benedicte Neven, Anna Simon,
Huri Ozdogan, Isabelle Touitou, Joost Frenkel, Michael Hofer, Alberto
Martini, Nicolino Ruperto and Marco Gattorno

Ann Rheum Dis published online January 30, 2015

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References This article cites 29 articles, 11 of which you can access for free at:
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